The Enduring Qualities in Midwiferyby Elizabeth Davis

I am so glad Jan chose trends vs. traditions as the theme for this issue! As midwifery is poised to go mainstream, we must be very clear on our foundation: What is essential to our work, and what is momentary or temporary? In other words, what about midwifery has endured, and what must endure if we are to continue to provide what women want when they seek midwifery care?

One of the easiest screens to determine what endures is quite personal. What qualities would you want in a midwife? How do you see her role in your pregnancy, birth and postpartum? Take a minute right now to make note, or better yet, envision yourself pregnant or birthing or with your newborn, and observe what the midwife does and does not do. This is an assignment I give my midwifery students, and the results are often surprising. Frequently, they envision the midwife on the perimeter throughout most or all of the labor, or perhaps standing quietly by while they catch the baby themselves. Postpartum care emerges as more important than expected—students see the midwife spending lots of time with them on a daily basis, being companionable and close. During pregnancy, they find they want information, support, respect and autonomy.

Threats to the existence of midwifery are, in the long view, relatively recent. The Inquisition took place only five hundred years ago, and in the US, midwifery was the standard of care not only for birth but for general women’s health issues until the early 1900s. Hospital birth didn’t really take hold until 1940. So we see that midwifery is the tradition, and obstetrics and medicalized birth, the trend. Women birth assistants, a tradition; male physicians assisting birth, a trend. Midwives are not “alternative” or “allied” health providers—we are the originals!

Still, the resurgence of midwifery in the US is rather miraculous. Perhaps midwifery was genetically encoded through the generations and then, after a major interruption, a core group of women woke up and remembered. This too is in our tradition, this desire to remember, or more than that, the will to remember.

It is particularly relevant to remember midwifery immediately before it was usurped by medicine, particularly in Europe where midwives had grown powerful. It is no accident that the Malleus Maleficarum, handbook of the Inquisition, states, “No one does more harm to the Catholic church than do the midwives,” thus identifying them as prime targets for torture and death. What did midwives know and do that was so threatening to the autocracy of the church?

They empowered women! They believed in the beauty of the body—it was certainly no “temple of sin,” nor were women “temptresses” to unwitting male attention. Midwives had witnessed first-hand the abuses women suffered at the hands of their partners, or from overwork, neglect or cultural oppression, and at times they aided women in terminating pregnancies to avoid threats to their own well-being or their family’s. They valued the mother as “the only direct health care provider for her unborn child” (from the MANA Statement of Values and Ethics). They shared the wisdom of the earth, of plant allies and of the need for good food and clean water. They were placeholders for women’s health, and therefore, family health. And they attended to family health needs throughout the lifecycle—not just at the time of birth.

Go back a little further in time, in Europe at least, and we find that midwives were also revered as spiritual guides for women and families at the climactic events not only of birth, but of death. They played pivotal roles in creating and conducting ritual at these junctures, as well as for the other Blood Mysteries of menarche and menopause. In other words, they provided care “from womb to tomb.” Today we define this as continuity of care, but more significantly, midwives held and preserved a continuum view of life that is all but lost in modern times. Scratch a midwife and you will find a woman fascinated by the interconnectedness of mind-body-spirit, well aware that good health incorporates this wholeness.

In his book, The Medium is the Message, sociologist Marshall McLuhan (who was quite ahead of his time) explained that technology drives changes in consciousness and therefore, lifestyle.

With the advent of birth technology (forceps, for example) came specialists more than happy to use their tools as much as possible. Specialization became a way of life, and we began to lose the continuum view. Now, when we meet people at parties we ask, “What do you do?” not, “How goes your life?” Specialization has also created hierarchy in health care: e.g., specialties and subspecialties, credentials of advanced training, etc. This brings us to the key hierarchical relationship in medicine: that of doctor and patient—a trend fully at odds with the midwifery tradition. With the locus of power on the doctor, the patient has no other option than to be patient! In contrast, the midwifery model values an egalitarian relationship between midwife and client. The two are in community together, and each is expected to uphold her share of the partnership.

Some subversion of the doctor/patient hierarchy has occurred of late with the surge in malpractice awards for less than perfect outcomes. The more patients are encouraged (or forced) to abdicate responsibility to their doctors, the greater the incidence of lawsuits. Here is an example of a trend resulting from another trend—something to be kept clearly in mind when considering any new technology or screening protocol coming through the medical model.

One of the advantages to working in any field for an extended period is the chance to see these trends come and go, and thus more clearly understand what lasts. Particularly in childbirth, trends are usually fueled by the development of new technology with concomitant opportunities for profit. Thinking back on the craze in the late 70s/early 80s for treating physiologic jaundice (which at the time was already understood by midwives to be self-correcting, particularly with breastfeeding on demand), one has to wonder if the development of bili-light technology didn’t have more to do with profit margin than any real physical indication. I thought this trend had died out; instead, it is once again emerging—but this time, I suspect some malpractice award underpins its resurgence.

Examples of questionable screening protocols abound: consider screening for gestational diabetes and GBS. One has only to look at the research to be convinced that gestational diabetes is indeed “a diagnosis looking for a disease,” and that risks for GBS infection of the newborn are less than slim for healthy term infants and that prophylactic antibiotic treatment encourages opportunistic infections. Seasoned midwives in particular expressed skepticism regarding these screening protocols when they were first introduced, and research has proved our suspicions sound. So perhaps one can say that midwifery’s trust in the body is a tradition that powerfully offsets trends for inappropriate screening and treatment.

This includes the inappropriate use of medications both now and in the past, such as Cytotec for induction, thalidomide for nausea or aspirin for fever in babies. Here, too, midwives have been wary, as well they should be. Our tradition shares a guiding principle attributed to one of the founders of modern medicine, Hippocrates: “First, do no harm.” If only medicine had not neglected this sacred charge (now omitted from oaths taken upon entering practice).

And then, we have ultrasound—the gold standard of perinatal screening. This technology has, on the whole, done more to undermine the midwifery model than any other. For one thing, it separates mother and baby: Early scanning has not, as some would claim, been shown to increase the bond between mother and child, but to objectify the baby as a separate entity at a time when union is essential. The use of ultrasound for the routine monitoring of healthy mothers and babies has further led to the loss of time-honored, core clinical skills of palpation and fetal heart auscultation, so that many physicians can no longer do either! Defense against malpractice is a factor too, in that ultrasound provides “objective” evidence as compared to a practitioner’s “subjective” assessment.

The latest research on ultrasound is chilling: abnormal migration of developing cortical neurons is clearly induced by prenatal ultrasound in mice. According to the study authors, “When the rate of neuronal migration and the sequence of arrival [in the cerebral cortex] are altered because of genetic or environmental factors, various consequences, including abnormal behavior, have been observed.”(1) Here, too, most midwives have been cautious; some, like I, have never used the Doppler for routine monitoring. This speaks to more than trust of the body—it’s about trust in nature, and the belief that technology must be suspect until proven harmless.

Respect for nature, for the physiology of birth, is the cornerstone of our midwifery tradition. More now than ever, we are realizing the power that this principle holds—if challenged in our work, we can fall back on physiology because it is virtually irrefutable. Ironically, malpractice proceedings have forced physicians to revisit physiology as they reevaluate standard practices and review the research. In other words, physiology has become a significant factor in shaping treatment. This last statement sounds preposterous, for what else would shape treatment? But we know the answer—technology, money, power and all the trimmings!

Yet another tradition in midwifery is inclusiveness—setting aside bias to give care. This means, for one thing, using our current political situation in a constructive way. It also means that our understanding of birth will be ever increasing, growing as we learn from the women and families we serve, from the research and from our elders in practice. As our global society begins to shape itself for the future, we have much to learn about cultural bias, which will expand the scope and skills of our work. In the best sense, tradition spirits the shaping of the future. In this, we midwives have so very much to contribute.